On SAGE Insight: PTSD and the War of Words

The importance of diagnostic categories: a reflection on the fluctuating names for posttraumatic stress disorder.

What’s in a name? In psychiatry, a great deal. The names for most psychiatric disorders reflect professional consensus rather than neuropathology. These names evolved over time. For example, dementia praecox became schizophrenia, manic-depressive illness became bipolar disorder, anxiety neurosis became panic disorder. These changes reflected important conceptual shifts, but in nearly all cases clinical wisdom survived the name transition. For reasons that are worth considering, post-traumatic stress disorder (PTSD) is an exception, as was documented for the first time in our paper: PTSD and the War of Words. In this we highlight the transition from shell shock in the World War I era, to battle fatigue in the World War II era, post-Vietnam syndrome following the Vietnam War, and PTSD introduced in 1980 with DSM-III. The paper clearly shows that frequent and sustained references to PTSD did not occur until after DSM-III. This commentary will consider briefly the importance and impact of these transitions.

It seems self-evident that the shifts in naming were associated with delayed progress in understanding PTSD, developing effective treatments for PTSD, assuring access to treatment for PTSD, and the provision of disability benefits to people with PTSD. When one of us (J.K.) first encountered veterans with PTSD shortly after the introduction of the PTSD diagnosis, it was evident that clinicians were struggling with the boundaries of PTSD and earlier diagnoses, such as borderline personality and major depression. When we began studying the neurobiology of PTSD in the 1980s, we were surprised to rediscover fascinating studies conducted in the World War I and World War II eras that had been forgotten. The impact of the delayed emergence of the PTSD is most obvious in the domain of pharmacotherapy. Unlike the disorders listed above, which underwent transformative development in the 1950s and 1960s, the first randomized controlled medication trial in PTSD was not published until 1988 and the first medication received FDA approval for the treatment of PTSD in 1999.

The shifts in name may reflect the unique challenge created by the highly contextualized nature of psychological traumas. PTSD as a diagnosis is distinguished from its predecessors by its universality, i.e., all traumas had the possibility of generating a common syndrome. Prior to PTSD, research was often distinguished by its particularity for example, “shell shock” was associated with the trench warfare of World War I, “Holocaust survivor syndrome” with the Nazi Death Camps, “rape trauma syndrome” as a consequence of sexual assault, etc. The horror of each of these events promotes an inward focus on the victims that enhances particularity. As a result, the field of PTSD research has struggled with the tension between particularity and universality. The distinct ways that the profession and popular media referred to PTSD, as documented in our paper, points to a dominance of the particular over the universal until the introduction of the PTSD diagnosis, with the seeming consequence of undermining lasting progress in the field.

Addressing the problem of PTSD almost always involves a need for mental health professionals and society to confront a deep truth that is actively avoided. The recognition of psychological consequences of combat and military sexual assault challenges the view of war as a glorious endeavor. The recognition of the high frequency of childhood abuse and neglect and the physical and sexual abuse of women challenges the societal wish to view families as “happy.” War created a unique temporal “window of empathy” for returning warriors and veterans, but in the absence of the diagnosis of PTSD these windows closed soon after the wars ended and remained closed until the next conflict. It is the responsibility of mental health professionals and society leaders to insure that we never forget the impact of PTSD and that we continue to develop better ways to de-stigmatize this disorder, to improve screening, to enhance access to effective treatments and prevention strategies, and to improve the safety and effectiveness of treatments.

By –

John H. Krystal, M.D.* (1,2,3,4)

Adam M. Chekroud, Ph.D. (1,5)

Department of Psychiatry, Yale University School of Medicine, New Haven, CT